Does "Evidence-Based Medicine" Diminish the Physician's Role?

Pennie Marchetti, MD; Robert M. Centor, MD; Robert W. Donnell, MD; Roy M. Poses, MD

Disclosures

January 05, 2007

In This Article

Have We Gone Too Far?: Robert W. Donnell, MD

Although the medical profession had recognized the value of applying scientific evidence to medical practice for decades, the EBM movement as we know it today was launched in 1992 with the publication of a seminal article in JAMA.[3] This article popularized the term "evidence-based medicine" and urged a more rigorous and disciplined approach to the incorporation of scientific evidence into medical practice.

The notion that doctors should apply the best available scientific evidence to patient care seems solid, and yet controversy abounds. Dr. Healy's recent column sounded a cautionary note about the movement by pointing out the adverse consequences of reduced physician autonomy and inadequate attention to the individualization of patient care.[1] She also expressed concern that EBM may be too rigid in defining what types of evidence are suitable.[1]

Has EBM gone too far? Yes and no! The basic ideas of EBM, although sound, have been distorted by some of its proponents. Therein lies the problem. In order to resolve the controversy, we must examine the original tenets of EBM as well as some of the distortions.

The classic article by Sackett and colleagues[4] describes EBM as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." This description addresses any detractors who might claim that EBM diminishes the importance of physician judgment (EBM is judicious) or that it doesn't allow for individualization (it's about the care of individual patients).

Still, some proponents have taken the good ideas of EBM to unhealthy extremes. Like thought police, they tell doctors who they should listen to and what they should read. EBM advocates often are correct to point out the hazards of basing treatment solely on pathophysiologic rationales (eg, inotropic agents for heart failure, and antiarrhythmic drugs to treat ventricular ectopic beats), but some have taken the idea too far. Most are careful to acknowledge the importance of understanding disease mechanisms, but I recently heard a speaker tell doctors that they should confine their reading to case-based references to answer clinical questions. Background reading about disease states or basic science ("disease-oriented evidence" in EBM parlance) was a waste of time and possibly dangerous, the speaker declared.

Some medical leaders would like to impose restrictions on continuing medical education by eliminating didactic lectures,[5] and others tell us that we shouldn't read medical journals.[6] One recent editorial was dismissive of 35 review articles on type 2 diabetes for not focusing on evidence that "mattered," then proceeded to set readers straight on what should matter.[7]

The de-emphasis on basic science has led some to criticize EBM as "cookbook medicine." EBM at its core is not cookbook medicine, but we disregard basic science and background reading at the risk for a dangerously formulaic approach, leading to increased mistakes in those patients who don't fit the algorithms. Our cerebral half-lives for disease-oriented literature and knowledge of pathophysiology are short after we leave medical school, and we need to review the material continually.

Sometimes, EBM proponents' insistence on patient outcome-based studies slows the wheels of medical progress. The American Heart Association 2005 guidelines for emergency cardiac care provide a recent example. Investigators at the University of Arizona, Tucson, have been publishing evidence for years in support of changes in emergency cardiac care for adult victims of out-of-hospital cardiac arrest.[8,9] Despite this evidence, the guideline authors, dutifully trying to be evidence-based, failed to adopt the new methods because of a reluctance to base changes on anything other than randomized trials. However, the evidence, although based on "low-level" physiologic rationale, was compelling. More recently, the Arizona investigators were vindicated by direct evidence that the new procedures save lives.[10] This situation represents a failure of EBM, not due to any shortcomings of EBM itself, but due to the misappropriation of its principles.

Like Dr. Healy, I'm cautiously optimistic about EBM in proper perspective. We must not forget its fundamental ideas, which seek to integrate the best and most current empiric evidence with the full range of scientific knowledge and clinical judgment. So, my advice to physicians is to become proficient in the tools of EBM, and to reap the benefits of case-based learning. Regularly review basic science and background material about disease. It's empowering; it leads to better patient care; and it's fun.

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